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The Value of Health Informatics
And how you pay for it
Nov 14th, 2018
Introduction
Rochester Regional Health
• Upstate New York, 5-hospital system– Approximately 1000 acute beds, 1000 skilled nursing beds,
more than 100 offices.
– More than a million ambulatory visits, 2,500 medical staff and 17,000 employees.
– Epic client since 2010, merger in 2014; most recent hospital go-lives in 2017. All Epic-based hospitals achieved HIMSS Stage 7 in 2017.
• Health Informatics – Medical Informatics, Clinical Informatics, Physician Advisors,
Utilization Review, Utilization Management, Quality Reporting
– Balazs Zsenits, MD, SVP, CMIO
– Matt Phillips, MBA, VP of Health Informatics
2
3
AGENDA
The EHR journey
Quality case study
Health Informatics: reason and goals
HI org structure and team examples
Value proposition and delivery
Lessons learned
Electronic Health Record Journey
As of 2015, electronic health
record adoption had doubled in
just seven years. 96 percent of
hospitals and 87 percent of
physician practices were using
electronic health records.
George W. Bush calls for computerized
health records in his State of the Union
address, supports the need for a plan to
give Americans access to electronic health
records within 10 years.
Institute of Medicine
(IOM) estimates that
“between 44,000 and
98,000 hospitalized
Americans die each year
as a result of
preventable medical
errors.”
1999
2004
2009
2015
Barack Obama signs Health Information
Technology for Economic and Clinical Health
(HITECH) Act as part of ARRA to adopt
electronic health records by 2014 and set
several stages of electronic health record
adoption - referred to as “meaningful use.”
$$$$
Meaningful Use put money on the table for physicians and hospitals to adopt and use EHRs.
Better data and
patient safety, yet the
EHR is a target of
criticism for burnout
2018
5
OUR JOURNEY
Rochester Regional Health was formed in 2014 via merger. It is committed to standardizing
technology and implementing system-wide applications that enable operational efficiencies and
clinical integration. In HIMMS Stage 7 we saw a validated milestone of excellence, to measure our
technical and behavioral readiness for a digital care transformation. Our Health Informatics
department was formed to focus on the Quadruple Aim, adding “Joy of Practice” to the Triple Aim.
Rochester General Hospital
2011
2017
January
Clifton Springs Hospital
April
Unity Hospital
2020
Our Future With Epic
Newark-Wayne Community Hospital
2012
Early EMR implementation success
and one of our HIMSS Stage 7 case studies
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HIMSS Stage 7 a Lasting Legacy
EMRAM stage distribution and prediction
Forecasting the Maturation of Electronic Health Record Functions Among US Hospitals: Retrospective Analysis and Predictive ModelHadi Kharrazi, MHI, MD, PhD; Claudia P Gonzalez, MBA; Kevin B Lowe, PhD; Timothy R Huerta, MS, PhD; Eric W Ford, PhD, MPH
Not until 2035 will 50% of US hospitals achieve HIMSS EMRAM Stage 7
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Health Informatics
A case study in quality
Medicine AG
Cli
nic
al O
pera
tio
ns
Cli
nic
al L
ead
ers
hip
IS &
T O
pera
tio
ns
SCSME IS
& T
Go
vern
an
ce
Health Informatics
A Case of an RCA-based RFC for Potassium Safety
HI Advisory Group’s original objective:
• clinician representation for
• approving & prioritizing requests (RFCs)
Specialty ChampionSubject Matter Expert
SC
SME
9
RCA = Root Cause Analysis
RFC = Request for Change
RCA – RFC for Potassium Safety
The first EMR build – and its effects
• Following up effect with
report
• Control chart showed no
statistical significance
10
System-wide - Clinical teams
SMS &
Spec/Surgical
AC
PCASI &
Amb/Comm
AC
CMOs &
Hospitals
AC
Specialized - Informatics teams
PCP AG
Amb Spec AG
Behav H AG
LTC AG
Pt Eng AG
HIE AG
Periop AG
Lab AG
Anesth AG
Surgical AG
Neuro AG
Hem/Onc AG
Heart Inst AG
OB-Gyn AG
Proc Spec AG
Consult AG
Medicine AG
Emerg AG
Imaging AG
Nursing AG
Allied H AG
Pharmacy AG
Qual & Eff AG
HIM/Reg AG
Ped AG
11
IS &
T G
overn
an
ce
Popul H AG
Rev Cycle AG
Cli
nic
al O
pera
tio
ns
Unity MDS
West Region
RGH MDS &
Region
CSH / NWCH
East Region
Cli
nic
al L
ead
ers
hip
Clinical Informatics domain expertise and subspecialties
Physician
EMR
Builders
STS Provider
Training &
Support
CI Nurse
AG/AC
Coordinators
SC
SC
SC
SC
SC
SC
SC
SC
SC
SC
SC
SC
SC
SC
SC
SC
SC
SC
SC
SC
SC
SC
SC
SC
SC
SC
SC
LMIDirDirDirDirDir
Dir Dir Mng
Mng
PBPBPBPBPBPB PBPBPBPBPBST PBPBPBPBCIC
MngDirDirDirDir
SME ITSMESMESMESME
RCA – RFC for Potassium Safety
IT4US approach by an expert HI team
HI – IT collaboration is a structured, team-
based, cyclical process
Clinical and project teams may connect with a
single informaticist or team Specialty Champion HI specialty team Subject Matter ExpertHI Med Director IT expert Operational leadDir
SC SME
IT
…
OL
IS &
T O
pera
tio
ns
11
RCA – RFC for Potassium Safety
Usable and effective solution
• No clinical event or high-risk
administration since BPA
• Statistically highly significant
and clinically meaningful
75% overall risk reduction
12
13
Health Informatics
The Business CaseVision and Goals
Health IT: why we need more now?
“It’s [not just] the economy, …”
• Scientific reductionist medicine• Biomedical: accurate clinical data
• Biopsychosocial medicine• Communication: with patient, caretakers, health care team
• Evidence based medicine• Clinical decision support: actionable access to accurate data and knowledge
• P4 medicine (Personalized, Predictive, Preventive, Participatory)• Precision medicine: “Impeding tsunami of additional knowledge [will] outstrip the
information and knowledge processing capabilities of practitioners [requiring] substantial computer-based assistance”*
• Prospective medicine: predictive analytics based on big data (detailed family, social, and environmental history, managing genomic information, etc.)
*Biomedical Informatics: Computer Applications in Health Care and Biomedicine; EH Shortliff, JJ Cimino: Springer 2014
Health IT– a strategic “enabler”
Health/Clinical Informatics is essential to optimize
• The Institute of Medicine (IOM) declared the EHR essential infrastructure for the delivery of healthcare. Like any other infrastructure project, the benefits specifically attributable to infrastructure difficult to establish; an infrastructure plays and enabling role in all projects
• [O]ptimization […], much like implementation, is an ongoing, difficult, and often expensive process. These include considerations relating to leadership, strategy, vision, and continuous cycles of improvement.*
• Clinical decision support systems […] can produce impressive benefits, namely improving the quality of care while reducing cost [and] competitive advantage. […] Technology capabilities often exceed an HCO’s ability to use them effectively and efficiently […] The handling of people and process issues has emerged as one of the most critical success factors […] The future vision […] can be achieved only [by] a cadre of talented individuals who not only comprehend computing and communication technology but also have a deep understanding of the biomedical milieu and of the needs of the practitioners and other health workers.**
*Cresswell KM et al. Ten key considerations for the successful optimization of large-scale health information technology. JAMIA. 2017; 24(1): 182-187
**Biomedical Informatics: Computer Applications in Health Care and Biomedicine; EH Shortliff, JJ Cimino: Springer 2014
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HEALTH
INFORMATICS
16
Vision
Optimize Information Technology for Usability and Safety, harvesting evolving best practices to empower our care teams and patient community, to leverage a fully integrated Electronic Medical Record experience to achieve clinical and service excellence.
Mission
Responsible to help set and implement standards and expectations in the Electronic Medical Record that optimize workflows and usability throughout the development cycle: planning, designing, communicating and reporting. Our goal is to excel in user experience and system resilience so that a fully paperless operation can maximize patient safety and produce measurably excellent outcomes. The team will support a fair governance system and collaborative culture to utilize informatics best practices in innovative projects and day-to-day operation, to achieve safe, clinically sound, user-friendly, compliant and efficient practices.
Information Technology
for
Usability & Safety
Optimizing the EMR
Strong Users and Great System
17
Strong Users
• Metrics– Signal, PEP, KLAS Arch Collaborative Survey– In progress: NEAT and IPEP
• Improvements – STS: eHuddle, Symposia, Portal, HI priority– In progress: NTN, Simulation lab
Great System
• Metrics– RRH measures: HIMSS Stage7, Magnet, JC…– Epic measures: Gold Stars, Honor Roll
• Improvements– RRH processes: RFC updates, SIDER updates– Epic processes: Refuel, Quarterly SUs
Heath Informatics
Connecting IT and clinical org structure
19
Health Informatics
Teams:Specialty Champions
Leading Advisory Groups
System-wide - Clinical teams Specialized - Informatics teams
PBs 15
(0.6 FTE)
CICs 5
(5 FTE)
Projects
PCP AG
Amb Spec AG
Behav H AG
LTC AG
Pt Eng AG
HIE AG
Periop AG
Lab AG
Anesth AG
Surgical AG
Neuro AG
Hem/Onc AG
Heart Inst AG
OB-Gyn AG
Proc Spec AG
Consult AG
Medicine AG
Emerg AG
Imaging AG
Nursing AG
Allied H AG
Pharmacy AG
Qual & Eff AG
HIM/Reg AG
Ped AG
20
IS &
T G
overn
an
ce
Popul H AG
Rev Cycle AG
Clin
ica
l O
pera
tio
ns
Unity MDS
West Region
RGH MDS &
Region
CSH / NWCH
East Region
Clin
ica
l L
ead
ers
hip
IS &
T O
pera
tio
ns
Clinical Informatics domain expertise and subspecialties
STs 18
(1.8 FTE)
Physician
EMR
Builders
STS Provider
Training &
Support
CI Nurse
AG/AC
Coordinators
SC
SC
SC
SC
SC
SC
SC
SC
SC
SC
SC
SC
SC
SC
SC
SC
SC
SC
SC
SC
SC
SC
SC
SC
SC
SC
SC
Specialty Champions 27 (2.5 FTE)
Dir Dir Mng
Mng
PBPBPBPBPBPB PBPBPBPBPBST PBPBPBPBCIC
Leaders , Directors, Managers 10 (5 FTE)
MngDirDirDirDir
8000+ FTE 300+ FTE2000+ RFCs 200+ SIDERs
SMS &
Spec/Surgical
AC
PCASI &
Amb/Comm
AC
CMOs &
Hospitals
AC DirDirDir LMIDirDir
HI org chart and staffing to support EMR change
Roles of Clinicians in
Health Informatics
Informatics Leader Roles–RRH regional leadership
> connect with CMO, CNO, President, VP)
– Informatics domain expertise>UCD, CDS, compliance, UAT, HCI,
HIE…
– Informatics team leadership>STS, CIC, PB
Proposal of Nurse Informatics
21
Specialty Champion Role
HI Roles in Optimization Decisions
Advisory Groups (AGs) and Specialty Champions (SCs)
Clinical/Business Operations
Information Technology
Needs
DesignBuild
Adopt
STRICT NEEDS ASSESSMENT❑ Build needed (R/O ineffective or duplicate)
❑ Priority validated (+urgency & IT track)
DESIGN COORDINATION❑ Operational stakeholders via AG/ACs (RACI)
❑ HI & IT standards (Order Set/CDS committees,
data structure reviewed for HIE/reporting)
BUILD INTERACTIVE WITH USERS❑ UCD (User Centered Design) process compliance
❑ UAT (User Acceptance Testing) completion
SUPPORTING ADOPTION❑ Materials: STRIDES, KB, HI priority 4US, metrics
❑ Live training & support: STS, eHuddle, PFLS
AG
22
• Prioritization: predictable and strategic
• Metrics: volume and timeliness
• Process: consistency and efficiency
23
Health Informatics
Teams:Specialist Trainers
Provider training and support
24
Multiple training and support modalities created to assist providersSTS (Specialist Training Specialist) Program:
Peer to peer provider training program for Epic and Dragon Medical One users.
• There are currently 18 STS trainers hailing from 5 different service lines:
– Inpatient Medicine
– Surgery
– Ambulatory Medicine
– Emergency Medicine
– Obstetrics/ Gynecology
• Some examples of training and support delivery methods:
– New hire reach out
– Elbow to elbow support
– Group support sessions
– Thrive classes (end-user optimization classes)
– eHuddle: On-line live meetings to teach
• STS Mechanics:
– Dedicated e-mail for training and support requests
– Tracking of all support sessions and training classes
– Ongoing feedback to classroom trainers based on classroom observations and end-user evaluation
– Regularly scheduled Team Share meetings with STS trainers, Care Connect classroom trainers, Business Partners, Provider
Front Line Support, and Go Live Support staff.
– Geographic assignment of STS trainers to ensure all hospitals and practices have adequate coverage
Portal updates
User-centric design for HI portal site
Deploying unified IT/HI/CC
interface with guidance on
the front portal page
EMR Training and Support
An Example: HI Symposium
• Topic selection based on–metrics and feedback
• Saturdays–6 hour course created and
presented by STS team
–Very good immediate feedback
Immediate satisfaction feedback 4.75 / 5 stars
0
5
10
15
20
25
10 of 10 9 of 10 8 of 10 7 of 10
September Ambulatory CareConnect Symposium
EMR Training and Support
Follow up on Symposium
• Follow up on efficiency– 100% subjective positive
feedback
–Confirmed by objective metrics
• Follow up plan–New Symposia
>Surgery and OB
–Cover evolving topics >Mobile technology
>Self serve analytics
>Population Health tools
Post-training utility feedback: 100% agreement
28
Health Informatics
Teams:HI Domain Experts:
Clinical Decision Support
Workload Capacity
Value
What has to be done?
How it has to be done?
- Fatigue
- Burnout
- Errors
- Workarounds
- Sustainable adoption
- Improvements
- Successful implementation
Implementation Strategy
Intervention Design
29
CDS - Team:
The Mission
CDS - Policy:
Operational and Technical Teams
• Assign a responsible Advisory Group/ Department/ Physician Champion for CDS existent content.
• Criteria selection to determine appropriateness of firing and exclusions needed.
• Determine date and time for re-review of the BPA and run analytics to measure efficiency and effectiveness of the CDS modalities.
• Determine a date and time to retire if not satisfying the intent in spite of above evaluation.
30
Score > 6: Consider ApprovingScore 1-5: Consider ImprovingScore < 0: Consider Rejecting
5 Rights Yes Neutral No Score
Right Information 3 0 -3
Right Person 1 0 -1
Right Format 1 0 -1
Channels Action as intended 3 0 -3
Right time in the workflow 2 0 -2
Total 0
CDS - Steering Committee 5 Rights:
A tool to grade requests
31
Initial Score for
Potassium Safety
RFC – Message in
order
Final Score for
Potassium Safety
RFC - BPA
32
Health Informatics
The Value PropositionUSSB Business Model
How to Pay for It?
• Understanding how to find value out of what is traditionally a support service
• RRH’s model for valuing Health Informatics:
– Usability
– Safety
– Strategic
– Benefit Cost Ratio
• Health Informatics' Challenge: Self fund a seven figure investment
33
How to Pay for It:
Value Attribution Model
•Hard Dollars
•Workload (FTE) reductions through automation, efficiency, direct error/rework reduction
•Soft Dollars
•Job satisfaction (burn-out, turn-over) and reduced distraction (error and efficiency)Usability
•Hard Dollars
•Avoidable costs attributable directly to safety event (cost of care, legal cost, penalties)
•Soft Dollars
•Reputational, operational and emotional cost and halo effect (additional risk reduction)Safety
•Hard Dollars
•Direct investment (FTE, resources) by HI in supporting the initiative
•Soft Dollars
•Opportunity cost and the BCR from the supported initiativeStrategic
•Hard Dollars
•Revenue generation and cost avoidance
•Soft Dollars
•Operational risk reductionBenefit/CostHI A
ttri
bu
tion
Mo
de
l
Core Mission
34
How to Pay for It:
Modeling an Initiative
• Assessment and proposal>Measure baselines processes
• Number of times process/event occurs• Historic outcomes (performance, costs, errors, etc.)
>Research proposed changes through literature and case studies> Predict effect and expected value of change
• Predefined and agreed upon financial valuation of impact (USSB and BCR models)
• Implementation>Request Reporting to track changes> Study actual changes in the measurements from process
• Validating and sustaining >Analyze changes (impact and control) in measures >Report metrics with predefined valuation
35
How to Pay for It:
Usability
Time savingsHard Savings: Reduction in time and/or workforce through usabilitySoft Savings: Generated efficiency of team members besides the direct time saving
Secondary gains
• Avoid distractions– Doubles error rate (11 → 22%)
– Overall efficiency (27% longer task completion)
• Error reduction– Cost of safety events and penalties
– Internal costs to work, fix
• Job satisfaction– Turn-over and burnout rate
– Physician efficiency and replacement cost ($500k)
36
How to Pay for It:
Safety
Hard and soft costs of a harm event
37
How to Pay for It:
Safety Example
Potassium administration safety project
• Assessment– High risk event when K >5.5
> Sporadic events, occasional serious outcome, hard to measure change
> Financial impact
• Lawsuit cost $171,198* per mortality (1 case in 4 years per chart review)
• Cost of care: $500-2000* per complication treated (2 cases in 4 y per chart review)
• Potential regulatory, emotional, reputational effect (hard to measure)
– Risk event when K >4.5> Baseline 35 events per week, reliable precursor of high risk event
> Use this metric to measure impact on safety
• Intervention> Initial intervention: order instructions. No significant improvement
> Second intervention: BPA. Statistically significant change (75% decline)
• Financial impact evaluation – Decrease in risk events (%) multiplied by the hard and soft costs
> Statistically significant reduction of >75%
• $171,198 / 4 * 0.75 = $32,100/year
2014-2017 data reviewed: Baseline Intervention
High K admin: 5819 reduced by 75%
Very high K admin: 29 expect 75% lower
Clinical event ($500): 1 expect 0.25/4y
Critical event ($2,000): 1 expect 0.25/4y
Legal event ($171,198): 1 expect 0.25/4y* Clinical and legal estimate
38
MyCare
How to Pay for It:
Strategic
39
SCCCC
Provider Satisfaction
Patient Satisfaction
HI infrastructure building
Projects
Culture
Initiatives do not impact ROI
but are strategically important,
are valued by charging our
time back
39
How to Pay for It:
Benefit/Cost Ratio
Direct financial effects:
• Revenue generation
• Cost reduction
• Operational risk reduction (at
risk $ * likelihood)
40
How to Pay for It:
USSB Model – Summing it up
• Health Informatics is an enabler for RRH– We need to capture what we enable– Value what we enable
>Measuring and valuing are not self-serving; they are tools for bringing change>Need to balance the work of valuation with the work of leading change
– Share with Operational and Clinical leaders the results and impact
• When financially valuing a project– Up front research – decide about need and limits of valuation– Design and create metrics – Ongoing reporting to show sustained impact
• Usage beyond HI– Framework and “value library”– IT/HI collaboration and other RRH projects and initiatives
41
How to Pay for It:
Project Tracker
42
Lessons Learned
Health Informatics plays a strategic role
– in transforming our Health Care delivery by
– improving how clinicians use and develop the EMR
In order to achieve its strategic goals, HI need to excel in tactical work
– in creating reliable and effective processes and
– measuring, valuing and reporting its own success in financial terms
43
Lessons Learned:
Future Opportunities
Our team-based HI processes, USSB value model, and user focused culture serves as a foundation for
– Strategic leadership> Engage with Epic programs to
further the EMR’s role in achieving the Quadruple Aim
– Cultural ambassadorship> Participatory User Centered
Design and improved communication
– Growth> Specialty areas and Nurse
Informatics
44
Contact Information
• Matthew Phillips, MBA – VP of HI– LinkedIn: https://www.linkedin.com/in/mattman545/
– Email: [email protected]
• Balazs Zsenits, MD – CMIO, SVP – LinkedIn: https://www.linkedin.com/in/balazs-zsenits-76b55a5a/
– Email: [email protected]
45
